Chest pain and Convex ST Elevation in Precordial Leads

A 30-something y.o. male with PMH significant for anxiety, asthma, and alcohol use disorder presented with chest pain x 1 week.  Patient thinks he has an asthma flare, with wheezing. He subsequently developed fevers and chills, and then left-sided chest pain associated with a cough. His breathing and infectious sx then improved. Today, however, he developed constant chest pain radiating into left arm around 1345. He states the pain is improving now. He had associated " swimmy, head rush, " which is no longer present. He denies associated shortness of breath, sweating, numbness, tingling. Onset of pain was while sweeping at work. He was able to ride bike on the day of presentation without difficulty.No cardiac history. Non-smoker, no EtOH, no h/o DVT. No leg swelling. No risk factors for CAD.Here is his ECG:There is ST elevation, up to 2.5 mm in V2, with convexity.Generally, STE with convexity in any of leads V2-V6 is abnormal and highly suggestive of ischemia (anterior MI, LAD occlusion).As always, pre-test probability is critical.  And this patient's pretest probability was extremely low.One is not supposed to use the formula that differentiates Normal Variant ST Elevation (often referred to as early repolarization) when there is convexity.  However, if one did, here is the result:QTc = 428 msST Elevation at 60 ms after the J-point in lead V3 (STE60V3) = 2.5 mmR-wave amplitude in V4 (RAV4) = 12 mmTotal QRS amplitude in lead V2 (QRSV2) = 25 mm4-variab...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs

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